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Pages 986-990 (October 2016)
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Vol. 69. Issue 10.
Pages 986-990 (October 2016)
Scientific letter
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Structural Heart Disease in Anticoagulated Patients With Nonvalvular Atrial Fibrillation: Prevalence and Clinical Profile in a Spanish Sample
Cardiopatía estructural en pacientes anticoagulados con fibrilación auricular no valvular: prevalencia y perfil clínico en una muestra nacional
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Martín Ruiz Ortiza,
Corresponding author
maruor@gmail.com

Corresponding author:
, Inmaculada Roldánb, Vicente Bertomeuc, Javier Muñizd, Francisco Maríne, Manuel Anguitaa, on behalf of the investigators of the FANTASIIA study
a Servicio de Cardiología, Hospital Reina Sofía, Córdoba, Spain
b Servicio de Cardiología, Hospital La Paz, Madrid, Spain
c Servicio de Cardiología, Hospital de San Juan, San Juan de Alicante, Alicante, Spain
d Departamento de Medicina Preventiva y Salud Pública, Instituto Universitario de Ciencias de la Salud, A Coruña, Spain
e Servicio de Cardiología, Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain
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Tables (2)
Table 1. General Characteristics of the Patients Included in the Study by Presence and Type of Structural Heart Disease
Table 2. General Characteristics of the Patients Included in the Study by Presence and Type of Heart Failure
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To the Editor,

Although the definition of nonvalvular atrial fibrillation (NVAF) varies,1,2 it generally does not exclude patients with structural heart disease (SHD), such as certain valve diseases. However, there is limited information on the frequency of this association in Spain. The objective of this article was to report the prevalence and clinical profile of patients with SHD and well as the prevalence of heart failure in a broad Spanish nationwide sample of patients with NVAF.

Data from the FANTASIIA registry3 were used. This registry included 2178 outpatients with NVAF who were receiving anticoagulation (according to protocol, the ratio of vitamin K antagonists to direct anticoagulants was 4:1). We excluded individuals younger than 18 years, those with prosthetic cardiac devices, those with any grade of mitral stenosis, and those with moderate or severe mitral regurgitation. Participants were enrolled consecutively between June 1, 2013, and October 15, 2014, in 50 Spanish centers selected by the investigators to ensure representation from throughout the country, with the primary objective of assessing the effectiveness of anticoagulation in patients with NVAF by type and quality of treatment. The diagnoses of SHD were taken from the medical records and included the following: coronary artery disease, hypertensive heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy, significant valve disease (aortic valve, tricuspid valve, or pulmonary valve disease of at least moderate intensity), and other heart diseases. Patients with coronary artery diseases and other concurrent heart diseases were classified as having coronary artery disease. The presence of heart failure was recorded independently. Overall, 47.15% of the sample had SHD (Table 1). The most frequent type of SHD was coronary artery disease (18.14%), followed by hypertensive heart diseases (11.43%), and dilated cardiomyopathy (6.01%). Hypertrophic cardiomyopathy was reported in 2.06% and significant valve diseases in 1.79%. Only 34 patients (1.56%) had isolated NVAF (age < 65 years, with no heart disease or embolic risk factor). Among patients with SHD, there were fewer women and there was a higher rate of cardiovascular risk factors, comorbidities, heart failure, permanent atrial fibrillation, and severe symptoms, and greater embolic and hemorrhagic risk. These patients also had worse left ventricular ejection fractions and renal function, as well as lower hemoglobin levels. Most of the drug classes were more frequently prescribed in patients with SHD, except for angiotensin receptor blockers (prescribed with a similar frequency) and antiarrhythmics and direct anticoagulants (prescribed less often). Overall, 27.23% of the patients had heart failure, with differential characteristics with respect to the sample, similar to patients with SHD, with a few exceptions (Table 2). Studies in Spain have reported a prevalence of coronary artery disease of between 10% and 20% in anticoagulated patients with NVAF,4–6 a similar prevalence to that reported in our study. The CALIFA registry is the only one of these studies to report frequencies of hypertensive heart failure (15.7%) and valve disease (4%) in Spain.4 These frequencies are similar to those reported in our registry (11.4% and 2%, respectively). It is possible that exclusion of patients with moderate or severe mitral regurgitation could partly explain this low frequency of heart disease. In the case of heart failure, previous studies have reported frequencies between 22% and 24%,4–6 which are similar to those observed in this series. A limitation of the present study is that several design features (anticoagulation in the 6 months prior to inclusion, exclusion of hospitalized patients, the willingness of the physicians involved in the registry, etc) could have resulted in a biased sample, and so extrapolation of our results to the overall population with NVAF should be made with caution. Furthermore, classification of heart disease was performed using medical records, which, although a true reflection of everyday clinical practice, may have heterogeneous application of diagnostic criteria. Nevertheless, our results, obtained in a large Spanish sample of consecutive patients with NVAF, suggest that almost half have SHD and more than quarter have heart failure. These patients had a different clinical profile to the other patients with NVAF and they received direct anticoagulants less frequently.

Table 1.

General Characteristics of the Patients Included in the Study by Presence and Type of Structural Heart Disease

Variable  All  No SHD  SHD  P1  Coronary artery disease  HTHD  DCM  HCM  Valve disease  Othersa  P2 
Patients, n  2178  1151  1027    395  249  131  45  39  79   
Demographic data
Age, y  73.78 ± 9.42  73.58 ± 9.23  74 ± 9.62  .239  74.37 ± 8.91  75.86 ± 9.08  69.49 ± 10.55  68.36 ± 11.89  79.1 ± 6.61  73.61 ± 10.21  < .001 
Female sex, %  43.85  48.74  38.36  < .001  26.33  54.22  21.37  24.44  58.97  48.1  < .001 
Cardiovascular risk factors and concurrent disease
Hypertension  80.39  77.85  83.25  .002  86.33  96.39  63.36  68.89  76.92  74.68  < .001 
Hyperlipidemia  52.3  46.57  58.71  < .001  71.9  50.6  54.2  51.11  28.21  41.77  < .001 
Diabetes mellitus  29.57  22.76  37.2  < .001  44.56  36.55  32.82  13.33  20.51  27.85  < .001 
Current smoker  6.08  3.8  .015  3.8  3.21  6.87  4.44  3.8  .189 
Exsmoker  32.05  26.76  37.98  < .001  49.87  26.9  48.09  22.22  30.77  26.58  < .001 
COPD/OSA  17.54  14.07  21.42  < .001  22.53  24.1  19.85  15.56  17.95  17.72  < .001 
Renal failure  18.92  13.21  25.32  < .001  29.37  22.09  25.19  13.33  28.21  21.52  < .001 
Liver dysfunction  1.1  1.04  1.17  .779  1.52  0.8  2.56  2.53  .533 
Previous CVA  17.13  16.42  17.92  .355  20.76  14.46  15.27  20  17.95  16.46  .427 
Modified Charlson comorbidity index  1.14 ± 1.15  0.73 ± 0.92  1.6 ± 1.21  < .001  1.72 ± 1.28  1.46 ± 1.07  1.85 ± 1.15  1.33 ± 1.13  1.46 ± 1.33  1.34 ± 1.15  < .001 
Cardiac history
Heart failure  27.23  57.74  < .001  50.63  56.62  95.89  51.11  41.02  51.89  < .001 
Preserved ejection fraction (>45%)  14.97  31.74  < .001  21.77  45.78  7.63  51.11  38.46  44.3  < .001 
Depressed ejection fraction (<45%)  12.26  26    28.86  10.84  86.26  2.56  7.59   
AF-related information
Permanent AFb  49.42  43.94  55.56  < .001  51.65  57.43  64.12  51.11  51.28  67.09  < .001 
EHRA functional class III-IVb  8.06  4.01  12.57  < .001  11.9  13.29  9.16  11.11  20.51  12.66  < .001 
CHADS2scale  2.25 ± 1.25  1.86 ± 1.11  2.69 ± 1.25  < .001  2.78 ± 1.26  2.82 ± 1.19  2.6 ± 1.32  2.11 ± 1.17  2.54 ± 1.25  2.39 ± 1.19  < .001 
CHA2DS2-VASc scale  3.7 ± 1.59  3.23 ± 1.42  4.23 ± 1.62  < .001  4.68 ± 1.57  4.28 ± 1.46  3.53 ± 1.66  3.07 ± 1.54  4.21 ± 1.47  3.71 ± 1.59  < .001 
HAS-BLED scale  2.01 ± 1.05  1.89 ± 0.96  2.14 ± 1.11  < .001  2.39 ± 1.15  2.15 ± 0.98  1.72 ± 1.15  1.6 ± 1.12  2.28 ± 1.17  1.86 ± 1  < .001 
Examination and diagnostic procedures at initial visit
Left bundle branch block  7.25  3.55  11.37  < .001  11.28  8.13  23.62  11.11  8.11  7.69  < .001 
Ejection fraction, %  58.72 ± 11.09  61.8 ± 7.28  55.34 ± 13.35  < .001  52.57 ± 14.04  60.4 ± 9.59  42.6 ± 13.53  65.91 ± 6.98  61.51 ± 6.99  60.92 ± 7.92  < .001 
Hemoglobin, g/dL  13.66 ± 1.71  13.82 ± 1.65  13.48 ± 1.75  < .001  13.49 ± 1.76  13.49 ± 1.6  13.78 ± 1.74  14.26 ± 1.61  12.34 ± 1.81  13.27 ± 1.81  < .001 
Pharmacological therapy
Diuretics  57.38  47.33  68.59  < .001  61.93  75.5  77.86  60  64.1  75.95  < .001 
Aldosterone antagonist  13.88  6.56  22.05  < .001  21.57  17.67  51.91  13.33  10.26  15.19  < .001 
ACEI  31.18  24.06  39.12  < .001  42.64  33.33  57.25  26.67  20.51  35.44  < .001 
ARB  40.13  39.98  40.29  .883  39.34  53.01  29.01  33.33  20.51  39.24  < .001 
Statins  54.57  45.58  64.59  < .001  87.82  52.21  55.73  46.67  35.9  40.51  < .001 
Antiplatelet agents  10.42  4.46  17.07  < .001  39.09  2.41  4.58  7.69  1.27  < .001 
Beta-blockers  60.29  52.06  69.46  < .001  72.59  63.45  85.5  82.22  48.72  51.9  < .001 
Digoxin  18.04  14.26  22.24  < .001  17.51  19.68  41.22  20  25.64  24.05  < .001 
Calcium antagonists
Dihydropyridines  13.65  12.95  14.44  .00317.51  18.07  3.82  8.89  15.38  8.86  < .001
Verapamil  2.4  2.71  2.05  1.02  3.21  0.76  6.67  2.53 
Diltiazem  8.03  9.97  5.85  7.11  6.43  4.58  2.22  7.69  5.06 
Antiarrhythmics  24.82  28.35  20.88  < .001  19.8  22.49  16.79  37.78  20.51  13.92  < .001 
VKA  75.51  72.09  79.32  < .00179.7  79.12  83.21  82.22  76.92  77.22  .006
ODAC  24.49  27.91  20.68  20.3  20.88  16.79  17.78  23.08  22.78 

ACEI, angiotensin converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; COPD/OSA, chronic obstructive pulmonary diseases/obstructive sleep apnea syndrome; CVA, cerebrovascular accident; DCM, dilated cardiomyopathy; EHRA, European Heart Rhythm Association; HCM, hypertrophic cardiomyopathy; HTHD, hypertensive heart disease; ODAC, oral direct anticoagulants; SHD, structural heart disease; VKA, vitamin K antagonist. P1, comparison between patients with SHD and without SHD (Mann-Whitney test for continuous variables and chi-square test for categorical variables); P2, comparison between patients without SHD, coronary artery diseases, HTHD, DCM, HCM, valve diseases, and others (Kruskal-Wallis test for continuous variables and chi-square test for categorical variables).

a

Congestive heart disease, congenital heart disease, pericardial disease, others.

b

According to the European Society of Cardiology.1

c Flecainide, propafenone, amiodarone, dronedarone, or sotalol.

Quantitative data expressed as mean ± standard deviation and qualitative data as percentages.

Table 2.

General Characteristics of the Patients Included in the Study by Presence and Type of Heart Failure

Variable  All  Without HF  With HF  P1  HF conserved  HF impaired  P2 
Patients, n  2178  1585  593    326  267   
Demographic data
Age, y  73.78 ± 9.42  73.7 ± 9.15  73.99 ± 10.1  .541  75.42 ± 9.84  72.23 ± 10.15  < .001 
Female sex  43.85  45.68  38.95  .005  53.07  21.72  < .001 
Cardiovascular risk factors and concurrent disease
Hypertension  80.39  79.87  81.79  .317  88.04  74.16  < .001 
Hyperlipidemia  52.3  49.15  60.71  < .001  55.21  67.42  .003 
Diabetes mellitus  29.57  25.3  40.98  < .001  44.79  36.33  .044 
Current smoker  5.43  3.88  .14  2.45  5.62  .055 
Exsmoker  32.05  29.38  39.96  < .001  29.45  52.81  < .001 
COPD/OSA  17.54  15.33  23.44  < .001  23.01  23.97  .846 
Renal failure  18.92  14.64  30.35  < .001  27.61  33.71  .127 
Liver dysfunction  1.1  1.14  1.01  .805  0.92  1.12 
Previous CVA  17.13  16.85  17.88  .57  15.64  20.6  .132 
Modified Charlson comorbidity index  1.14 ± 1.15  0.78 ± 0.94  2.11 ± 1.12  < .001  2.11 ± 1.07  2.11 ± 1.18 
Cardiac history
No heart disease  55.10  74.50  0.00  < .0010.00  0.00  < .001
Coronary artery disease  18.91  12.62  36.76  30.39  43.68 
Hypertensive heart diseases  11.92  6.99  25.92  40.28  10.34 
Dilated cardiomyopathy  6.27  0.52  22.61  3.53  43.30 
Hypertrophic cardiomyopathy  2.15  1.42  4.23  8.13  0.00 
Valve disease  1.87  1.49  2.94  5.30  0.38 
Other heart diseasesa  3.78  2.46  7.54  12.37  2.30 
AF-related information
Permanent AFb  49.42  45.13  60.88  < .001  60.12  61.8  .827 
EHRA functional class III-IVb  8.06  4.56  17.37  < .001  18.09  16.47  .332 
CHADS2scale  2.25 ± 1.25  1.92 ± 1.1  3.12 ± 1.2  < .001  3.24 ± 1.09  2.99 ± 1.3  .013 
CHA2DS2-VASc scale  3.7 ± 1.59  3.35 ± 1.43  4.63 ± 1.65  < .001  4.87 ± 1.49  4.34 ± 1.77  < .001 
HAS-BLED scale  2.01 ± 1.05  1.93 ± 1  2.2 ± 1.14  < .001  2.24 ± 1.03  2.15 ± 1.25  .346 
Examination and diagnostic procedures at initial visit
Complete left bundle branch block  7.25  3.8  16.47  < .001  9.97  24.43  < .001 
Ejection fraction, %  58.72 ± 11.09  61.68 ± 7.65  51.17 ± 14.45  < .001  60.29 ± 8.3  40.14 ± 12.48  < .001 
Hemoglobin, g/dL  13.66 ± 1.71  13.75 ± 1.67  13.41 ± 1.78  < .001  13.2 ± 1.75  13.67 ± 1.78  .001 
Pharmacological therapy
Diuretics  57.38  49.46  78.41  < .001  78.22  78.65  .920 
Aldosterone antagonist  13.88  6.73  32.88  < .001  19.63  49.06  < .001 
ACEI  31.18  26.29  44.18  < .001  36.2  53.93  < .001 
ARB  40.13  40.51  39.12  .558  42.94  34.46  .042 
Statins  54.57  51.49  62.73  < .001  58.28  68.16  .013 
Antiplatelet agents  10.42  8.51  15.51  < .001  13.5  17.98  .139 
Beta-blockers  60.29  54.6  75.38  < .001  69.02  83.15  < .001 
Digoxin  18.04  14.41  27.66  < .001  21.78  34.83  < .001 
Calcium antagonists
Dihydropyridines  13.65  14.41  11.64  .00615.34  7.12  .001
Verapamil  2.4  2.6  1.85  2.15  1.5 
Diltiazem  8.03  8.95  5.56  7.36  3.37 
Antiarrhythmicsc  24.82  26.86  19.39  < .001  21.47  16.85  .175 
VKA  75.51  73.46  80.94  < .00180.06  82.02  .599
ODAC  24.49  26.54  19.06  19.94  17.98 

ACEI, angiotensin converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; COPD/OSA, chronic obstructive pulmonary diseases/obstructive sleep apnea syndrome; CVA, cerebrovascular accident; EHRA, European Heart Rhythm Association; HF, heart failure; ODAC, oral direct anticoagulants; SHD, structural heart disease; VKA, vitamin K antagonist. P1, comparison between patients with HF and without HF (Mann-Whitney test for continuous variables and chi-square test for categorical variables); P2, comparison between patients with HF and conserved systolic function and patients with HF and depressed systolic function (Kruskal-Wallis test for continuous variables and chi-square test for categorical variables).

a

Congestive heart diseases, congenital heart diseases, pericardial disease, others.

b

According to the European Society of Cardiology.1

c

Flecainide, propafenone, amiodarone, dronedarone, or sotalol.

Quantitative data expressed as mean ± standard deviation and qualitative data as percentages.

FUNDING

This study was funded with a research grant from Pfizer/Bristol-Myers-Squibb.

References
[1]
A.J. Camm, P. Kirchhof, G.Y. Lip, U. Schotten, I. Savelieva, S. Ernst, et al.
Guías de práctica clínica para el manejo de la fibrilación auricular.
Rev Esp Cardiol., 63 (2010),
1483.e1-e83
[2]
G. Boriani, P. Cimaglia, E. Fantecchi, V. Mantovani, M. Ziacchi, C. Valzania, et al.
Non-valvular atrial fibrillation: potential clinical implications of the heterogeneous definitions used in trials on new oral anticoagulants.
J Cardiovasc Med (Hagerstown)., 16 (2015), pp. 491-496
[3]
I. Roldán Rabadán, M. Anguita Sánchez, F. Marín, M.A. Quesada, J. Camacho Siles, R. Peinado, et al.
Tratamiento antiarrítmico actual de la fibrilación auricular en España. Datos del registro FANTASIIA.
Rev Esp Cardiol., 69 (2016), pp. 54-60
[4]
M. Anguita Sánchez, V. Bertomeu Martínez, A. Cequier Fillat, en representación de los investigadores del estudio CALIFA.
Calidad de la anticoagulación con antagonistas de la vitamina K en España: prevalencia de mal control y factores asociados.
Rev Esp Cardiol., 68 (2015), pp. 761-768
[5]
S. Cinza-Sanjurjo, D. Rey-Aldana, E. Gestal-Pereira, C. Calvo-Gómez, en representación del grupo de investigadores del estudio ANFAGAL.
Evaluación del grado de anticoagulación de pacientes con fibrilación auricular en el ámbito de atención primaria de Galicia.
Rev Esp Cardiol., 68 (2015), pp. 753-760
[6]
V. Barrios, C. Escobar, L. Prieto, G. Osorio, J. Polo, J.M. Lobos, et al.
Control de la anticoagulación en pacientes con fibrilación auricular no valvular asistidos en atención primaria en España. Estudio PAULA.
Rev Esp Cardiol., 68 (2015), pp. 769-776
Copyright © 2016. Sociedad Española de Cardiología
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